Ryan Zitnay Journal Club June 7, 2013

Case 80 year-old Haitian male clinic patient Being seen for routine f/up Daughter reports that pt has declined since last visit Memory worsening Increase in incontinence Poor appetite and hypoglycemic episodes More depressed Pt has stated “sometimes I think it would be better if I was not here anymore”

Case Social History: Past Medical History: Lives at home with wife & daughter (MA) in Randolph 1st floor apt ADH 4x/week Went to college, accountant in Haiti, retired Past Medical History: Blindness - Glaucoma Dementia Depression Diabetes Mellitus II HTN Hyperlipidemia Prostate cancer

Case Functional Status: ADLs: Assist required for feeding & transfers, otherwise dependent IADLs: Dependent Overall picture: Overall health status and life expectancy declining High comorbidity burden Functionally more dependent

Task at Hand Readdress goals of care & advanced directives Patient can participate somewhat in conversation Wife, daughter (HCP), and son were present Blessing and curse!

What evidence, if any, do you use in your advanced directives discussion? What factors/predictors of prognosis do you incorporate in your “recommendation”? Functional status? Functional status: Has been associated with worse outcomes (life expectancy etc) in other things…can we extrapolate to survival with resuscitation too?

Background Predictors of likelihood of survival after cardiac arrest Age: inadequate/controversial, >80-90 likely worse Chronic health conditions: CVA Initial cardiac rhythm ? Function: extrapolation from other known “outcomes” Age: inadequate predictor

Hypothesis Worse functional status will lead to worse outcomes after attempted in-hospital CPR Most profound in NH patients Less aggressive resuscitation efforts may play role in this Because NH patients have significant impairments in ADLs

Study Design Retrospective, cohort study Cardiac arrests reported to GWTG-R registry AHA sponsored Prospective, multi-site, observational In-hospital cardiac arrest Purpose of creating evidence based guidelines for inpatient CPR Jan 2000 – Feb 2008 GWTG-R registry: American Heart Association sponsored, prospective, multi-site, observational registry of in-hospital cardiac arrest; create evidence based guidelines for inpatient CPR

Study Design Stratified into 4 groups based on function & residential status: Independent with ADLs Dependent with ADLs Nursing home Community dwelling

Functional Status Determined by surrogate marker: Pre-arrest Cerebral Performance Category (CPC) scale 5 categories: 1 = Good cerebral performance 2 = Moderate cerebral disability 3 = Severe cerebral disability 4 = Coma or vegetative state 5 = Brain death NO PRIOR VALIDATION IN THIS CONTEXT Independent in ADLs Dependent Subjects stratified into 4 groups based on pre-arrest functional and residential status: Independent in ADLs if CPC 1-2 Dependent if 3+ CPC 4-5 excluded in primary analysis CPC originally developed to assess POST-ARREST neuro outcomes but in GWTG-R was used for pre and post arrest X = not included in primary analysis so that study sample was more typical of clinical practice (sensitivity analysis of these individuals was performed)

Inclusion/Exclusion Inclusion: Exclusion: Admitted inpatients 1st cardiac arrest On ICU, step-down, general med ward Exclusion: CPR limited/suspended due to AD/DNR Missing pre-admit CPC or prior residence

Outcomes Primary: Secondary: ROSC after attempted resuscitation Survival to hospital discharge Secondary: Survival with good or no worse neurological function

Other Measures Measures of Aggressiveness of CPR Duration Initiation of response -> end of effort (ROSC or termination) Total doses of epi or vasopressin Use & time of placing of DNR orders after ROSC

Statistical Analysis Bivariate analyses Multivariate logistic regressions to adjust for potential confounders (pg 35) Secondary regression Measures of aggressiveness with effect on results? Two-sided Student t-tests Mann-Whitney test

ENTER FIGU n = 26,329 235 hospitals 78% Community 11% NH

TABLE 1 Significant differences between the two groups for most of the baseline demographic and arrest characteristcs

Results: Achievement of ROSC Community dwelling subjects independent in ADLs were more likely to achieve ROSC than CD dependent and all NH residents; after adjusting for confounders only NH residents dependent in ADLs remained significantly less likely to achieve ROSC After adjusting for confounders Only NH dependent remained significant

Results: Survival to Discharge Adjusted analysis: Dependent in ADLs had lower survival regardless of residential status CD independent in ADLs had the highest survival to discharge

Results: Secondary Outcome Survival to discharge with good (CPC 1-2) or no-worse neuro outcome CD-I: 15% CD-D: 10%, p<.001 NH-I: 11%, p<.001 NH-D: 8%, p<.001

Aggressiveness & DNR Orders All groups received similar aggressiveness

Adjusted ROSC & Survival After adjusting for confunders, only dependent residents in ADLs remained significantly less likely to achieve ROSC; OR 0.79 Aggressiveness had no effect on results!

DNR Ordering Less implementation of DNR after ROSC in Independent CD Time to DNR order overall was 10 hrs average and no significant differences between the groups Less implementation of DNR after ROSC in Independent CD No difference in time

Discussion Functional & residential status are important predictors of survival in IN-HOSPITAL cardiac arrest NH dependents less likely to achieve ROSC All dependents less likely to survive to d/c And it’s NOT because they receive less aggressive resuscitation!

Limitations Retrospective, cohort design GWTG-R may not represent all in-hospital cardiac arrests Convenience sample, self-reported, voluntary ? Interest in improving quality Corresponds with Medicare database Reliability & validity of pre-arrest CPC as proxy for dependence

Conclusions Not so surprising, but does provide evidence! Functional status known to affect mortality in hospitalized patients NH pts tend to be more functionally dependent

Will this affect your advance care planning discussions regarding CPR with your patients?

Back to Case… Thank you!!